Coverage Definition

Medical Deductible

$250 per person

What is Medical Deductible?

The Medical Deductible is a co-pay amount which is the responsibility of the insured. Options vary by plan and can range from $0 to $2500. Deductibles can be charged 1) per policy; or 2) per person; or 3) per occurrence, injury or illness; or 4) combination of the above. Most Long Term Plans require you to select a deductible option while most Vacation plans offer a zero deductible benefit.

What am I covered for?

Deductible

$0, $100, $250, $500, $1,000, $2,500. Deductible is per person per Period of Coverage. Maximum of 3 Policy Period Deductibles per family.

The term “Deductible” shall mean the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits
under the Policy are payable by the Company.

Definitions

The term “Accident” or “Accidental” shall mean an event, independent of Illness or self inflicted means, which is the direct cause of bodily Injury to an Insured Person.

The term “Airworthiness Certificate” shall mean the “Standard” Airworthiness Certificate issued by the Federal Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil aviation in the country of its registry.

The term “Benefit Period” shall mean the one hundred and eighty (180) days following the onset of an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses.

The term “Company” shall mean Certain Underwriters at Lloyd’s, London.

The term “Coinsurance” shall mean the percentage amount of eligible Covered Expenses, after the Deductible, which are the responsibilities of the Insured Person and must be paid by the Insured Person. The Coinsurance amount is stated in Section II, Schedule of Benefits, under each stated benefit.

The term “Common Carrier” shall mean any public air conveyance operating under a valid license providing for the transportation of passengers for hire.

The term “Congenital” shall mean a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.

The term “Covered Expense” shall mean “Eligible Benefit”.

The term “Deductible” shall mean the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits under the Policy are payable by the Company.

The term “Disablement” as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Policy.

The term “Eligible Benefit(s)” shall mean benefits payable by the Company to reimburse expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary charges; incurred while insured under this program and which do not exceed the maximum benefit.

The term “Emergency” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger if medical attention is not provided within 24 hours.

The term “Experimental / Investigational” means all services or supplies associated with: 1) treatment or diagnostic evaluation which is not generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of effectiveness documented in peer reviewed articles in medical journals published in the United States. For the treatment or diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available: or if less effective than other available treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR 807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical journals published in the United States. For the device to be considered effective, such articles should indicate that it is more effective than other available devices for the proposed use; or if less effective than other available devises, or is safer or less costly. The Company will make the final determination as to whether a service or supply is Experimental/Investigational.

The term “Hospital” as used in this Policy shall mean except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision.

The term “Home Country” shall mean the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.

The term “Host Country” shall mean any country other than the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.

The term “Illness” wherever used in this Policy shall mean a sickness, disorder, illness, pathology, abnormality, malady, morbidity, affliction, disability, defect, handicap, deformity, birth defect, congenital defect, symptomatology, syndrome, malaise, infection, infirmity, ailment, disease of any kind, or any other medical, physical or health condition. Provided, however, that Illness does not include learning disabilities, or attitudinal or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another are considered to be one Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation of the prior Illness and not a separate Illness.

The term “Injury” wherever used in this Policy shall mean bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while this Policy is in force and resulting directly and independently of all other causes in Disablement covered by this Policy.

The term “Insured” or “Insured Person” shall mean a person eligible for benefits under the Policy who has applied for coverage and is named on the application and for whom the company has accepted premium.

The term “Intensive Care” shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

The term “Loss” in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, shall mean the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through and above the wrist or ankle joints, and with regard to eyes, entire irrecoverable Loss of sight.

The term “Medically Necessary” shall mean services and supplies received while insured that are determined by the Company to be: (1) appropriate and necessary for the symptoms, diagnosis, or direct care and treatment of the Insured Person’s medical conditions; (2) within the standards the organized medical community deems good medical practice for the Insured Person’s condition; (3) not primarily for the convenience of the Insured Person, the Insured Person’s Physician or another Service Provider or person; (4) not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and (5) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person’s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such treatment Medically Necessary or make the charge of a Covered Expense under this Policy.

The term “Mental Illness” and “Mental and Nervous Disorder” shall mean any mental, nervous, or emotional Illness which generally denotes an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include without limitation: psychosis; depression; schizophrenia; bipolar affective disorder; any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by the U.S. Department of Health and Human Services; and those psychiatric and other Mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. Mental Illness and Mental and Nervous Disorder does not mean or include learning disabilities, attitudinal disorders or disciplinary problems. For purposes of this insurance, Mental Illness and Mental and Nervous Disorder do not include Substance Abuse.

The term “Other Policy” as used in this Policy shall mean an insurance plan or policy other than this policy that provides medical, repatriation of remains, and/or medical evacuation b enefits for the Insured Person.

The term “Outpatient” shall mean an Insured Person who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is not confined and is not charged for room and board.

The term “Policy Period” or “Period of Coverage” shall mean the Period of Coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Termination Date or the date coverage is renewed by the Company.

The term “Physician” as used in this Policy shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists.

The term “Pre-Existing Condition” as used in this Policy shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or any time during the 36* months prior to the effective date of coverage under this policy, whether or not previously manifested , symptomatic, known, diagnosed , treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury , Illness, disease , Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the 36 month period immediately preceding the effective date of coverage under this policy. *For Insured Persons traveling outside the United States and Canada, the period is 12 months instead of 36 months.

The term “Primary Health Plan” is a Group Health Benefit Plan, an individual health benefit plan, or a governmental health plan (Medicare is excluded) designed to be the first payor of claims for an Insured Person in effect prior to the effective date of this Policy and continuing as long as this Policy is in effect. Such plans must have coverage limits in excess of $50,000 per incident or per year to be considered a Primary Health Plan.

A “Group Health Benefit Plan” means a group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services. The term does not include: 1. accident-only, credit or disability insurance coverages; 2. specified disease coverage or other limited benefit policies; 3. long-term care, dental care, or vision care coverages; 4. coverage provided by a single service health maintenance organization; 5. insurance coverage issued as a supplement to liability insurance; 6. insurance coverage arising out of a workers’ compensation system or similar statutory system; 7. automobile medical payment insurance coverage; 8. jointly managed trusts authorized under 29 U.S.C. Section 141 et seq. that contain a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 U.S.C. Section 157; 9.hospital confinement indemnity coverage; or 10. reinsurance contracts issued on a stop-loss, quota share, or similar basis.

PLEASENOTE: Your Primary Health Plan must be effective at the time of claim. Medicaid, Medicare, and V.A. health plans do not constitute primary health insurance.

The term “Reasonable and Customary” shall mean the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses the Insured Person receives, up to but not to exceed charges actually billed. The Company’s determination considers: (1) amounts charged by other Service Providers for the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; (2) any usual medical circumstances requiring additional time, skill or experience; and (3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.

The term “Sound Natural Tooth” or “Sound Natural Teeth” is a tooth that is whole or properly restored; is without impairment, periodontal or other conditions; is not more susceptible to Injury than a virgin tooth, and is not in need of the treatment provided for any reason other than Accidental Injury. A tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or Treated by endodontics, is not a Sound Natural Tooth.

The term “Substance Abuse” shall mean a condition brought about when an individual uses alcohol, chemicals or any other drug(s) in such a manner that his/her health and/or judgement is impaired and/or ability to control actions is lost.

The term “Surgery” shall mean an invasive diagnostic procedure; or the treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.

The term "Terrorist Activity” shall mean an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or government(s).

1. Pre-existing Conditions which are excluded under this policy. This means that any claims for Pre-existing Conditions will not be covered for the duration of this policy.

a) If you are a United States citizen and the United States is your Home Country, this exclusion is waived for Eligible Benefits incurred outside the United States and Canada as defined below:

1) For persons less than age 65 with a Primary Health Plan as defined in the policy, Pre-Existing Conditions are waived up to the medical maximum selected.

2) For persons less than age 65 without a Primary Health Plan as defined in the policy, Pre-Existing Conditions are waived up to the first $20,000.

3) For persons age 65 and over, Pre-Existing Conditions are waived up to the first $2,500 regardless of whether there is a Primary Health Plan. This waiver does not include coverage for known, scheduled, required, required or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program.

b) If you are a non-United States citizen and suffer a Myocardial Infarction or Stroke and are admitted to a Hospital, this exclusion is waived only in order to pay a $200 per night benefit for each night spent in the Hospital, up to a maximum benefit of $3,000. The term “Myocardial Infarction” shall require an acute and emergent onset of the condition. The term “Stroke” shall require an acute and emergent onset of the condition.

2. Charges for Treatment(s) of the following Illness(es) or Surgery(ies), which Manifest(ed) themselves or are recommended, or symptoms occur during the first one hundred and eighty (180) days of Coverage hereunder beginning on the initial Effective Date: any condition of the breast; any treatment of all forms of cancer/neoplasm; any condition of the prostate; disorders of the reproductive system; hysterectomy; gall stones or urologic stones (kidney, ureteral, bladder or urethral stones) and any associated complications; any acne diagnosis or acne related condition; asthma; allergies; tonsillectomy; back conditions; adenoidectomy; hemorrhoids; hemorrhoidectomy; hernia, or any Surgery(ies) that is(are) not Emergency in nature, as Emergency is defined hereunder. (Does not apply to United States citizens traveling outside of the United States and Canada)

3. Claims not received by Seven Corners within ninety (90) days of the date of service;

4. Charges for treatment which exceed Reasonable and Customary charges; or Charges incurred for Surgeries or treatments which are Investigational, Experimental, or for research purposes; expenses which are nonmedical in nature;

5. Expenses for Vocational, Speech, Recreational or Music Therapy;

6. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;

7. Suicide or any attempt thereof; self-destruction or any attempt thereof; intentionally self-inflicted Injury or Illness;

8. Expenses as a result of or in connection with the commission of a felony or any other criminal or illegal activity as defined by the local governing body;

9. War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not. For the purpose of this Exclusion; ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;

10. Terrorist Activity. For the purpose of this Exclusion, Terrorist Activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist Activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of Terrorist Activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).The Company shall not be liable for and will not provide coverage or benefits in excess of a $50,000 lifetime maximum benefit for any claim or charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any act of Terrorism; and provided, further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following: a) The Insured Person’s direct or indirect involvement in the Terrorist Activity. b) The Terrorist Activity takes place in a country or location where the United States government has issued a travel warning that has been in effect within the six (6) months prior to the Insured Person’s date of arrival. c) The Insured Person unreasonably fails or refuses to depart a country or location following the date a warning to leave that country or location is issued by the United States government.

11. Injury sustained while participating in professional athletics, including but not limited to the event, games, practice, conditioning and any other activity related to professional athletics.

12. Injury sustained while participating in amateur or interscholastic athletics, including but not limited to the event, games, practice, conditioning and any other activity related to amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.

13. Routine physicals, innoculations, or other examinations including but not limited to laboratory, diagnostic, or x-ray examinations where there are no objective indications or impairment in normal health;

14. Treatment of the Temporomandibular joint;

15. Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person;

16. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery (including deviated nasal septum), routine dental expenses, eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while insured hereunder;

17. Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent; injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor, chemicals, or drugs or narcotic agent,unless administered under the advice of a Physician and said narcotic agent was taken in accordance with the proper dosing as directed by the physician;

18. Any Mental and Nervous disorders or Rest Cures;

19. Congenital abnormalities and conditions arising out of or resulting therefrom;

27. Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident;

28. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;

29. Expenses incurred while the Insured Person is in their Home Country (except after approved Emergency Medical Evacuation / Repatriation or if treatment is a follow-up to a covered disablement during coverage (see Home Country Coverage Benefit) or if the expenses pertain to the Home Country Coverage Benefit);

30. Expenses incurred for which travel was undertaken to seek medical treatment for a condition;; or incurred after the Insured Person’s physician has limited or restricted travel.

31. Expenses incurred as a result of the Insured’s failure to accept or follow a Physician’s advice, treatment, or recommended treatment.

With regards to Accidental Death and Dismemberment, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Emergency Medical Reunion, and Return of Minor Child, this Insurance does not cover:

1. Suicide or attempt thereof by the Insured Person while sane or self destruction or any attempt thereof by the Insured Person while insane;

5. Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting, from any type of aircraft;

6. Injury sustained while the Insured Person is riding as a passenger in any aircraft (a) not having a current and valid Airworthy Certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;

7. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with the following: war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.

a) mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power.

b) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto or to the influencing of it by terrorism or violence.

c) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the “Occurrences”).

Any consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Company shall not be liable under this plan except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such abnormal conditions.

8. Service in the military, naval or air service of any country;

9. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing, endurance tests, rocket-propelled aircraft, crop dusting or seeding or spraying, fire fighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose;

10. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified physician or surgeon;

11. Injury occasioned or occurring while the Insured Person is committing or attempting to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation;

12. Riding or driving in any kind of competition;

13. Pregnancy, childbirth, miscarriage or abortion;

14. Covered Expenses incurred after the Insured Person’s physician has limited or restricted travel;; or Covered Expenses incurred as a result of a change in prescribed treatment during, or within the three (3) months prior to the effective date of coverage.

For Interruption of Trip, this insurance does not cover: (1) war or any act of war, whether declared or not; participation in a felony, riot or insurrection; participation in contests of speed; a Pre-existing Condition existing prior to the Insured’s departure from their Home Country that has the likelihood of causing death; the Insured Person or Traveling Companion or Traveling Companion’s family making changes to personal plans;; having business or contractual obligations;; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather); prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Insured Person purchased their trip arrangements.

For Loss of Checked Luggage, this insurance does not cover: animals; automobiles or automobile equipment; boats; motors; motorcycles; other conveyances or their appurtenances (except bicycles while checked as baggage with a Common Carrier); household furniture; eye glasses or contact lenses; artificial teeth or dental bridges; hearing aids; prosthetic limbs; musical instruments; money or securities; tickets or documents; or sporting equipment if loss or damage results from the use thereof.